Moderate evidence supports that neuraxial anesthesia could be used in total knee arthroplasty (TKA) to improve select perioperative outcomes and complication rates compared to general anesthesia.

Rationale
There were six high-quality (Nielsen PT 1990, Nielson WR 1990, Mitchell 1991, Jorgensen 1991, Williams-Russo P 1995, Williams-Russo P 1996) and three low-quality (Sharrock 1991, Stundner 2012, Memtsoudis 2013) studies evaluating whether neuraxial anesthesia (“spinal or epidural”) reduces complications or improves outcomes in adult patients undergoing knee arthroplasty compared to general anesthesia.
 
Two high-quality studies (Nielsen PT 1990, Jorgensen 1991) and one low-quality (Sharrock 1991) study demonstrated significantly lower rates of deep venous thrombosis (DVT) compared to general anesthesia.  Of note, the two high-quality studies did not utilize any form of perioperative prophylactic anticoagulation; and the low-quality study utilized postoperative aspirin therapy only. Neither study used warfarin or low-molecular weight heparin as part of their postoperative DVT prophylactic regimen.  Four additional low- (Stundner 2012, Memtsoudis 2013) quality studies demonstrated significant reductions in overall postoperative complications with neuraxial anesthesia; including reductions in blood transfusion rates, pulmonary compromise, pulmonary embolism, pneumonia, mechanical ventilation rates, acute renal failure and composite infectious complications.
 
Two high-quality studies demonstrated improved short-term functional outcomes after neuraxial anesthesia.  Specifically, Williams-Russo (1996) demonstrated improved short-term range-of-motion (flexion) and short-term ambulation (days until unassisted stair climbing) compared to general anesthesia.  Nielson WR (1990) demonstrated improved short-term cognitive function (Wechsler Memory Scale; Controlled Oral Word Association) compared to general anesthesia.
 
One low-quality study (Memtsoudis) demonstrated a significant reduction in 30-day mortality in patients undergoing neuraxial anesthesia compared to general anesthesia.
 
  1. Jorgensen,L.N., Rasmussen,L.S., Nielsen,P.T., Leffers,A., Albrecht-Beste,E. Antithrombotic efficacy of continuous extradural analgesia after knee replacement. Br J Anaesth. 1991/1; 1: 8-12
  2. Memtsoudis,S.G., Sun,X., Chiu,Y.L., Stundner,O., Liu,S.S., Banerjee,S., Mazumdar,M., Sharrock,N.E. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. 2013/5; 5: 1046-1058
  3. Mitchell,D., Friedman,R.J., Baker,J.D.,III, Cooke,J.E., Darcy,M.D., Miller,M.C.,III Prevention of thromboembolic disease following total knee arthroplasty. Epidural versus general anesthesia. Clin Orthop Relat Res 1991/8; 269: 109-112
  4. Nielsen,P.T., Jorgensen,L.N., Albrecht-Beste,E., Leffers,A.M., Rasmussen,L.S. Lower thrombosis risk with epidural blockade in knee arthroplasty. Acta Orthop Scand. 1990/2; 1: 29-31
  5. Nielson,W.R., Gelb,A.W., Casey,J.E., Penny,F.J., Merchant,R.N., Manninen,P.H. Long-term cognitive and social sequelae of general versus regional anesthesia during arthroplasty in the elderly. 1990/12; 6: 1103-1109
  6. Sharrock,N.E., Haas,S.B., Hargett,M.J., Urquhart,B., Insall,J.N., Scuderi,G. Effects of epidural anesthesia on the incidence of deep-vein thrombosis after total knee arthroplasty. J Bone Joint Surg Am 1991/4; 4: 502-506
  7. Stundner,O., Chiu,Y.L., Sun,X., Mazumdar,M., Fleischut,P., Poultsides,L., Gerner,P., Fritsch,G., Memtsoudis,S.G. Comparative perioperative outcomes associated with neuraxial versus general anesthesia for simultaneous bilateral total knee arthroplasty. Reg Anesth.Pain Med 2012/11; 6: 638-644
  8. Williams-Russo,P., Sharrock,N.E., Haas,S.B., Insall,J., Windsor,R.E., Laskin,R.S., Ranawat,C.S., Go,G., Ganz,S.B. Randomized trial of epidural versus general anesthesia: outcomes after primary total knee replacement. Clin Orthop Relat Res 1996/10; 331: 199-208
  9. Williams-Russo,P., Sharrock,N.E., Mattis,S., Szatrowski,T.P., Charlson,M.E. Cognitive effects after epidural vs general anesthesia in older adults. A randomized trial. 1995/7/5; 1: 44-50